Tài liệu NEW ADVANCES IN THE BASIC AND CLINICAL GASTROENTEROLOGY docx

NEW ADVANCES IN THE

BASIC AND CLINICAL

GASTROENTEROLOGY

Edited by Tomasz Brzozowski

NEW ADVANCES IN THE

BASIC AND CLINICAL

GASTROENTEROLOGY

Edited by Tomasz Brzozowski

New Advances in the Basic and Clinical Gastroenterology

Edited by Tomasz Brzozowski

Published by InTech

Janeza Trdine 9, 51000 Rijeka, Croatia

Copyright © 2012 InTech

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Publishing Process Manager Vana Persen

Technical Editor Teodora Smiljanic

Cover Designer InTech Design Team

First published April, 2012

Printed in Croatia

A free online edition of this book is available at www.intechopen.com

Additional hard copies can be obtained from [email protected]

New Advances in the Basic and Clinical Gastroenterology, Edited by Tomasz Brzozowski

p. cm.

ISBN 978-953-51-0521-3

Contents

Section 1 Emerging Impact of Probiotics in Gastroenterology 1

Chapter 1 Intestinal Microbial Flora –

Effect of Probiotics in Newborns 3

Pasqua Betta and Giovanna Vitaliti

Chapter 2 Probiotics – What They Are,

Their Benefits and Challenges 21

M.S. Thantsha, C.I. Mamvura and J. Booyens

Chapter 3 The Impact of Probiotics

on the Gastrointestinal Physiology 51

Erdal Matur and Evren Eraslan

Chapter 4 The Benefits of Probiotics in

Human and Animal Nutrition 75

Camila Boaventura, Rafael Azevedo,

Ana Uetanabaro, Jacques Nicoli

and Luis Gustavo Braga

Chapter 5 Gut Microbiota in Disease Diagnostics 101

Knut Rudi and Morten Isaksen

Chapter 6 Delivery of Probiotic Microorganisms

into Gastrointestinal Tract by Food Products 121

Amir Mohammad Mortazavian,

Reza Mohammadi and Sara Sohrabvandi

Section 2 Pathomechanism and Management

of the Upper Gastrointestinal Tract Disorders 147

Chapter 7 Chronic NSAIDs Therapy and Upper

Gastrointestinal Tract – Mechanism of

Injury, Mucosal Defense, Risk Factors for

Complication Development and Clinical Management 149

Francesco Azzaroli, Andrea Lisotti, Claudio Calvanese,

Laura Turco and Giuseppe Mazzella

VI Contents

Chapter 8 Swallowing Disorders

Related to Vertebrogenic Dysfunctions 175

Eva Vanaskova, Jiri Dolina and Ales Hep

Chapter 9 Enhanced Ulcer Recognition from

Capsule Endoscopic Images Using Texture Analysis 185

Vasileios Charisis, Leontios Hadjileontiadis and George Sergiadis

Chapter 10 Methods of Protein Digestive

Stability Assay – State of the Art 211

Mikhail Akimov and Vladimir Bezuglov

Chapter 11 Mesenteric Vascular Disease 235

Amer Jomha and Markus Schmidt

Chapter 12 A Case Based Approach to

Severe Microcytic Anemia in Children 247

Andrew S. Freiberg

Section 3 Pathophysiology and Treatment of

Pancreatic and Intestinal Disorders 267

Chapter 13 Emerging Approaches for the

Treatment of Fat Malabsorption

Due to Exocrine Pancreatic Insufficiency 269

Saoussen Turki and Héla Kallel

Chapter 14 Pharmacology of Traditional Herbal

Medicines and Their Active Principles

Used in the Treatment of Peptic Ulcer,

Diarrhoea and Inflammatory Bowel Disease 297

Bhavani Prasad Kota, Aik Wei Teoh and Basil D. Roufogalis

Chapter 15 Evaluating Lymphoma Risk in

Inflammatory Bowel Disease 311

Neeraj Prasad

Chapter 16 Development, Optimization and

Absorption Mechanism of DHP107, Oral Paclitaxel

Formulation for Single-Agent Anticancer Therapy 357

In-Hyun Lee, Jung Wan Hong, Yura Jang,

Yeong Taek Park and Hesson Chung

Chapter 17 Differences in the Development of the Small Intestine

Between Gnotobiotic and Conventionally Bred Piglets 375

Soňa Gancarčíková

Chapter 18 Superior Mesenteric Artery Syndrome 415

Rani Sophia and Waseem Ahmad Bashir

Contents VII

Chapter 19 Appendiceal MALT Lymphoma in

Childhood – Presentation and Evolution 419

Antonio Marte, Gianpaolo Marte,

Lucia Pintozzi and Pio Parmeggiani

Chapter 20 The Surgical Management of Chronic Pancreatitis 429

S. Burmeister, P.C. Bornman, J.E.J. Krige and S.R. Thomson

Chapter 21 The Influence of Colonic Irrigation

on Human Intestinal Microbiota 449

Yoko Uchiyama-Tanaka

Section 4 Diseases of the Liver and Biliary Tract 459

Chapter 22 Pancreato-Biliary Cancers –

Diagnosis and Management 461

Nam Q. Nguyen

Chapter 23 Recontructive Biliary Surgery in the

Treatment of Iatrogenic Bile Duct Injuries 477

Beata Jabłońska and Paweł Lampe

Chapter 24 Hepatic Encephalopathy 495

Om Parkash, Adil Aub and Saeed Hamid

Chapter 25 Adverse Reactions and Gastrointestinal Tract 511

A. Lorenzo Hernández, E. Ramirez

and Jf. Sánchez Muñoz-Torrero

Chapter 26 Selected Algorithms of Computational

Intelligence in Gastric Cancer Decision Making 529

Elisabeth Rakus-Andersson

Section 1

Emerging Impact of

Probiotics in Gastroenterology

1

Intestinal Microbial Flora –

Effect of Probiotics in Newborns

Pasqua Betta* and Giovanna Vitaliti

U.O UTIN, Department of Pediatrics,

University of Catania

Italy

1. Introduction

The surface of the human gut has a surplus area of 200-250 m2 in order to contain, between

intraepithelial lymphocytes and lamina propria, Peyer’s patches and lymphoid follicles, the

lymphoid tissue, while hosts a flora of about 800 different bacteria species with over 7000

strains. The 99% are obligate anaerobes and varies species were then classified using

traditional anaerobic culture techniques. More than 50% of the dominant gut microbiota

(corresponding to 10 8-10 11 per gram of faeces) cannot be identified using traditional colture

,but molecular approaches, based on the use of 165 ribosomal DNA molecular (Mai &

Morris, 2004). Most of these bacteria colonizes the large intestine (in a range of 10-12

bacteria/g). The bacterial count of the small intestine (duodedum and jejunum) is

considerably lower (approximately 104-7 bacteria/ml) than Streptococcus Lactobacillus,

Enterobacteriaceae corresponding to the transient microbiota.

The main bacterial species represented in the human large intestine (colon) are distributed

with densities higher than 10 9-11 per gram of contents, and these high densities can be

explained by the slow transit and low redox potential . In this intestinal tract we can mostly

find bifidobacteria and bacteroides ,bifidobacterium clostridium. The fecal microbiota

contains 10 9 _10 11 CFU per gram, and microorganism in about 40% of their weight. The

dominant microbiota is represented by strict anaerobes , while the sub-dominant microbiota

by facultative anaerobes. In addition to the resident microbiota (dominant and sub

dominant), the faeces contain the transient microbiota, that is extremely variable, including

Enterobacteriacee (Citrobacter, Klebsiella, Proteus ) and Enterobacter (Pseudomonas) and

yeast ( Candida) CFU per gram (Table 1) (Zoetendal et al, 2004).

2. Intestinal microbiota in newborn

The normal human microflora is a complex ecosystem that somehow depends on enteric

nutrients for establishing colonization. At birth ,the digestive tract is sterile. This balance of

the intestinal microflora is similar to that of adult from about two years of age (Hammerman

et al, 2004).

*

Corresponding Author

4 New Advances in the Basic and Clinical Gastroenterology

Mouth 200 species

Stomach,duodenum pH 2,5-3,5 destructive to most of

bacteria 101_103 unit /ml

Lactobacillus,Streptococcus,

Jejunum,ileum 10 4_ 10 6 unit /ml bifidobacteria and

bacteroides ,bifidobacterium

clostridium

Aerobes

Colon 300-400 several species 1010_ 1011 unit

/ml

Enterobacteriacee (Citrobacter,

Klebsiella,Proteus)o(Pseudomonas)

Candida.

Anaerobes

Table 1. Composition and topographical features of intestinal microbiota

Diet and environmental conditions can influence this ecosystem. At birth intestinal

colonization derives from microorganism of the vaginal mucoses of the mother and faecal

microflora . The microbial imprinting depends on the mode and location of delivery.

Literature data shows that infants born in a hospital environment, by caesarean section, have a

high component of anaerobic microbial flora (Clostridia) and high post of Gram-negative

enterobacteria. Those born prematurely by vaginal delivery and breast-feed have a rather rich

in Lactobacilli and Bifidobacteria microflora. (Grönlund et al, 1999; Hall et al, 1990)

Diet can influence the microbiota, while breast-feeding promotes an intestine microbiota in

which Bifidobacteria predominate, while coliform, enterococci and bacteroides predominate

in formula bottle-fed baby.

Escherichia coli and Streptococcus are included among the first bacteria to colonize the

digestive tract. After them, strict anaerobes (Bacteroides, Bifidobacteri ,Clostridium)

establish during the first week of life, when the diet plays a fundamental role. (Mackie et al,

1999). The pattern of bacterial colonization in the premature neonatal gut is different from

the one of healthy, full term infant gut. Aberrant pre-term infants admitted to NICU, born

by caesarean section, are more often separated from their mother and kept in an aseptic

intensive care setting, treated with broad-spectrum antibiotics. This is the reason why they

show a highly modified bacterial flora, consisting of less than 20 species of bacteria, with a

predominance of Staphylococcus (aureus and coagulase negative) among aerobic micro￾organisms, and Enterobacteriaceae (Klebsiella), among enterococci and anaerobic Clostridia

(Dai et al, 1999; Gothefor, 1989).

It is believed that microbial diversity is an important factor in determining the stability of

the ecosystem and that the fecal loss of diversity predisposes the preterm gastrointestinal

colonization of antibiotic-resistant bacteria and fungi colonization with a consequent

potential risk of infection, thus contributing to the development of necrotizing enterocolitis

(NEC) (Fanaro et al, 2003; Sakata et al, 1985)

2.1 Structure and function of intestinal microbial flora

The intestinal microbial flora has numerous functions, even if the most of them has not yet

been identified. Among these functions, we can report its anatomical –functional role, its

Intestinal Microbial Flora – Effect of Probiotics in Newborns 5

protective function, in particular the “barrier effect”, referring to the physiological capacity

of the endogenous bacterial microflora to inhibit colonization of the intestine by pathogenic

microorganism. It is already known that the intestinal microbial flora influences food

digestion ,absorption and fermentation, the immune system response, peristalsis,

production of vitamins such as B-vitamins, influencing moreover the turnover of intestinal

epithelial cells. In addition the metabolism of gut microflora influences hormonal secretion.

Bacterial colonization of human gut by environmental microbes begins immediately after

birth; the composition of intestinal microbiota, relatively simple in infants, becomes more

complex with increasing in age, with a high degree of variability among human individuals.

It is believed that microbial diversity is an important factor in determining the stability of

the ecosystem and that fecal loss of diversity predisposes the preterm gastrointestinal

colonization of antibiotic-resistant bacteria and fungi with the consequent potential risk of

infection (Cummings & Macfarlane, 1991; Montalto et al, 2009; Neish, 2002).

2.2 Gut microflora and immunity

The mucosal membrane of the intestines, with an area of approximately 200 m2, is

constantly challenged by the enormous amount of antigens from food, from the intestinal

microbial flora and from inhaled particles that also reach the intestines. It is not surprising

therefore that approximately the eighty per cent of the immune system is found in the area

of the intestinal tract and it is particularly prevalent in the small intestine. The intestinal

immune system is referred as GALT (gut-associated-lymphoid tissue). It consists of Peyer’s

patches, which are units of lymphoid cells, single lymphocytes scattered in the lamina

propria and intraepithelial lymphocytes spread in the intestinal epithelia.

The immune system of infants is not fully developed. The structures of the mucosal immune

system are fully developed in utero by 28 weeks gestation, but in the absence of intrauterine

infections, activation does not occur until after birth. Maturation of the mucosal immune

system and establishment of protective immunity is usually fully developed in the first

years of life. In addition the exposure to pathogenic and commensal bacteria, the major

modifier of the development patterns in the neonatal period, depends on infant feeding

practices. (Brandtzaeg, 2001; Gleeson et al, 2004)

Bacterial colonisation of the intestine is important for the development of the immune

system. The intestine has an important function in working as a barrier.This barrier is

maintained by tight-junctions between the epithelial cells, by production of IgA antibodies

and by influencing the normal microbial flora. It is extremely important that only harmless

substances are absorbed while the harmful substances are secreted via the faeces.

Studies show that individuals allergic to cow´s milk have defective IgA production and an

increased permeability of the intestinal mucosa. This results in an increased absorption of

macromolecules by the intestinal mucosa. The increased permeability is most probably

caused by local inflammations due to immunological reactions against the allergen. This

damages the intestinal mucosa

2.3 Modification of the intestinal flora micro-ecosystem

During the past century our lifestyle has dramatically changed regarding hygienic

measures, diet, standards of living and usage of medical drugs. Today our diet largely

6 New Advances in the Basic and Clinical Gastroenterology

includes industrially produced sterilized food and the use of different kinds of

preservatives. This has led to a decreased intake of bacteria, particularly lactic acid

producing bacteria .

The widespread use of antibiotics in healthcare and agriculture, antibacterial substance is

also something new for human kind. We have in so many ways sterilized our environment,

which is detrimental to the microbial (Cummings & Macfarlane G.T., 1997; Vanderhoof &

Young, 1998).

3. What are probiotics?

The term ‘probiotic’ was proposed in 1965 to denote an organism or substance that

contributes to the intestinal microbial balance. The definition of probiotics has subsequently

evolved to emphasise a beneficial effect to health over effects on microbiota composition,

underscoring the requirement of rigorously proven clinical efficacy. Most probiotic bacterial

strains were originally isolated from the intestinal microbiota of healthy humans and the

probiotics most thoroughly investigated thus far belong to the genera lactobacilli and

bifidobacteria (Caramia G., 2004).

Probiotics have several effects, including modulating the gut microbiota, promoting

mucosal barrier functions, inhibiting mucosal pathogen adherence and interacting with the

innate and adaptive immune systems of the host, which may promote resistance against

pathogens. The intestinal microbiota constitutes an important aspect of the mucosal barrier

the function of which is to restrict mucosal colonisation by pathogens, to prevent pathogens

from penetrating the mucosa and to initiate and regulate immune responses

3.1 Proved beneficial effects on the host

Prerequisites for probiotics’ efficacy are human origin, resistance transit gastric capacity to

colonize survival in and adhesion, competitive exclusion of pathogens or harmful antigens

to specific areas of the gastrointestinal tract, vitality, verifiable and stability conservation,

production substances with antimicrobial action, exclusion of resistance transferable

antibiotic. No pathogenicity and / or toxicity has ever been demonstrated on the host.

3.2 Effect of probiotics

Among their effects, the most important are: competition to the more valid nutrients and

enteric epithelial anchorage sites; reduction of intestinal pH values for high production of

lactic acid from lactose and acetic acid from carbohydrates, which selects the growth of

lactobacilli; production of bacteriocins, peptides with bactericidal activity towards related

bacteria species; metabolism of certain nutrients in the volatile fatty acids; activation of

mucosal immunity, with increased synthesis of secretory IgA, and phagocytosis; stimulation

of production of various cytokines

3.3 Mechanism of action of probiotics

The functional interactions between bacteria, gut epithelium, gut mucosal immune system

and systemic immune system are the basis of the mechanisms of direct and indirect effects

of probiotics. The direct effect of probiotics in the lumen are: competition with pathogens for

Intestinal Microbial Flora – Effect of Probiotics in Newborns 7

nutrients, production of antimicrobial substances and in particular organic acids

competitive inhibition on the receptor sites, change in the composition of mucins hydrolysis

of toxins, receptorial hydrolisis, and nitric oxide (NO), while the indirect effect largely

depends on the site of interaction between the probiotic and the effectors of the immune

response, topographically located in the intestinal tract.

There is evidence, in vitro and in vivo, on effects of different probiotics on specific

mechanisms of the immune response. The starting point is the interaction between probiotic

and the host intestinal mucosa, but it seems clear that not all probiotics have the same initial

contact (immune cells, enterocytes, etc.).

There are several literature data that have demonstrated the interaction between probiotics

and the immune system, in particular it has been demonstrated their capacity to stimulate

the production of intestinal mucines, their trophic effect on intestinal epithelium, the re￾establishment of the intestinal mucosa integrity, the stimulation of the IgA-mediated

immune response against viral pathogens. All these effects have been demonstrated in

experimental studies and in some clinical studies, even if it is not still clear the main

mechanism of action and it is conceivable that different mechanisms of action contribute to

the efficacy of probiotics, with a different role in different clinical situations (Vanderhoof &

Young, 1998).

3.4 Safety

The oral consumption of viable bacteria in infancy naturally raises safety concerns. Products

containing probiotics are widely available in many countries and, despite the growing use of

such products in recent years, no increase in Lactobacillus bacteraemia has been detected.

Nevertheless, the average yearly incidence of Lactobacillus bacteraemia in Finland between

the years 1995 and 2000 was 0.3 cases/100,000 inhabitants. Importantly, 11 out of the 48

isolated strains were identical to Lactobacillus GG, the most commonly used probiotic

strain. Lactobacillus bacteraemia is considered to be of clinical significance; immune￾suppression, prior prolonged hospitalisation and surgical interventions have been identified

as predisposing factors. Nonetheless, clinical trials with products containing both

lactobacilli and bifidobacteria have demonstrated the safety of these probiotics in infants

and children, and in a recent study, the use of L. casei was found to be safe also in critically

ill children

In a trial assessing the safety of long-term consumption of infant formula containing B. lactis

and S. thermophilus, the supplemented formulas were demonstrated to be safe and well

tolerated. No serious adverse effects have been reported in the trials involving premature

neonates, but it should be noted that the studies were not primarily designed to assess their

safety (Hammerman et al, 2006)

4. Probiotics and gastrointestinal disorders

The presence of Bifidobacteria in artificial milk can contribute to the induction of a

significant increase of Bifidobacteria in the intestinal tract, promotes the development of a

protective microflora, similar to that one of the breast- fed newborn, contributes to the

modulation of immune-defenses, giving them a major efficiency (Langhendries et al, 1995;

Fukushima et al, 1998).